HOD, Radiology and Imaging
Fortis Escort Heart Institute, New Delhi
Sr. Consultant & Coordinator
Fortis Memorial Research Institute, Gurgaon
President, Cardiological Society of India
</b> Dear Friends, It is really a good pleasure and honor indeed for me to be here this morning on the occasion of WCCPCI-2015 in the campus of BK Headquarters at Abu Road, Shantivan. I have very important people here today. They are the authorities worldwide known, Dr. Mona Bhatia, chief of MRI and Imaging Center in Escort Fortis Hospital in Delhi and I have with me Dr. M. L. Bera who is a Chief of Imaging in the Fortis Hospital, Gurgaon. Imaging is a very important modality. We know it in our heart. If there is no imaging, we cannot know anything and will be totally blind in our understanding and in our management skills for any patient anywhere in the world. Imaging has really evolved over the last few years and there are so much of advances that are unbelievable. I am basically an echo man, also imaging, so I do a real time imaging by echo but number of times I have to take the help of CT scan and MRI as a multimodality approach, so that I can give a better outcome and better results. So, we have with us Dr. Mona Bhatia, a very pleasant lady. Let me see what she is to speak.Mona, you are welcome on this platform.
</b> Hello, pleasure to be here.
</b> I really want to ask you what do you think is the role of cardiac MRI in the years to come because do you feel is there a competition between the MRI authorities and the echo authorities or it is a complimentary and I let you to narrate some situations where echo could not pickup, but MRI did, Mona.
</b> Echo definitely remains the cornerstone for imaging because there is no way that we can do as many MRIs as we can do echos. If you talk about a stadium full of people and the total number of echos that can be done is maybe about 200 times in the same time as we would do MRIs in a single day. So, there is no question that MRI can never replace echo because of the facility being available on the bedside being very fast, rapid, cheap and available 24/7 in most institutions. When you are talking about cardiac MRI, it has definitely got a very limited availability. It has a limited number of institutions that are doing it and also the number of staffing that is required is different. The kind of clinical acumen required is different. So, it is not something that can replace echo at any given point even today. As far as cardiac MRI is concerned, the big advantage that cardiac MR today has is that it can assess the myocardium, something that echo could never do and no other modality could do to the same level of spatial resolution that we have with MRI. So, MRI can actually assess and characterize your myocardium which is where it is really important particularly in a country like ours, where we have tuberculosis, we have infections, we have myocarditis, we have little children who are less than one-month-old have a upper respiratory tract infection, come with a heart that is dilated working at 10% its value and then in these situations, we really need to look at the myocardium. If we can check for myocarditis and give them the immunoglobulins before we can even get the blood tests and have it approved on that then it really makes sense, because we have saved that child and that saved the child’s heart from any consequential damage. This is where we really think it makes a tremendous difference in the evaluation of myocarditis. There are a lots and lots of dilated cardiomyopathies that have always been there in our county who in the past have been idiopathic. They have never known what was the cause. Now, we know the infection, we know it is tuberculosis, we know we can treat it, we know we can improve it and we know that the patient will not have sudden cardiac death. So, all that can now be evaluated and averted.So, that is where we really need to look at it. There are a lot of cardiologists who come and say “I can handle the coronary artery disease and I can handle the ischemia. What I cannot handle is my patient dying because of sudden cardiac death. Can I prognosticate that patient and can I know which patient will have it” and that is where I think it makes a tremendous difference if we can prognosticate the patients who have a chance of sudden cardiac death, what we need to do to prevent it, so that is where it is important.
</b> I think Mona had given a very important insight that MRI has a huge potential in identifying the myocardiac disease whether it is an inflammatory disorder or a degenerative or an ischemic disorder and Mona was very, very emphatic on it that it is not only a diagnostic modality but also a prognostic modality and help us in the appropriate therapeutic intervention. Mona, I have one more question to you. I think we see these days a lot of CT angios and we know there are a lot of radiations given by the CT angios. When I say a lot of radiation means some people are more sensitive even to a small dose and most of our population is CKD. They have underlying diabetes or hypertension and they are highly vulnerable to have a contrast nephropathy even with a small dose. So dose is not a criteria, it is a sensitivity of an individual which is the criteria for treating more nephropathies. I would like to ask you is there MR angio in pipeline for coronaries or it is feasible and it is not practical in the years to come. What are your view points on this?
</b> It is definitely in the pipeline we have it in the future for sure. At present, what we can assess is the proximal segments of most of these arteries. So, proximal coronaries can be evaluated their origins. That part we can evaluate even today fairly well, but we still have not reached the level of sensitivity and the spatial and temporal resolution that CT angiography as a noninvasive modality has reached in the evaluation of coronary stenosis but for sure MR will definitely pave the way forward for this if we are talking about no radiation.
</b> We see a lot of renal artery stenosis in elderly patients, especially those who are diabetics, they have angiopathies, they have microangiopathy or middle vessel involvement or large vessel involvement and they already in CKD. So, as a clinician I feel MR angio of the renal vessels should be superior as compared to CT angio for the renal vessels. What is your opinion on this if you think of a CKD?
</b> For sure, the renal vessels can be very well assessed without any contrast on MR. So, MR has the capability to evaluate vasculature without any contrast. So that way as far all vessels other than the coronaries are concerned, MR can evaluate most vessels without any contrast and in the event of a CKD or in patients who have even disturbed renal functions even mildly, we definitely prefer the MR angiography to the CT.
</b> I think it is very important the message given by Dr. Mona Bhatia that MR angio is going to be the future, though it is very well validated of angios in the renal vessels or aorta or angio in the carotid or peripheral vessels, but so far if the coronaries concerned, it is only confined to the proximal part of the coronary vessels, but in the years to come and as the technology evolves, CT angio maybe replaced by MR angio that will be a revolution. Thank you Mona for your nice comments.
</b> Pleasure being here.
</b> We have with us Dr. M. L. Bera. I know him for last many years and he is a very good academician and the authority far excellence in the imaging. Dr. Bera, you are doing a lot of angios, CT angios and advances in CT, does it really help in the last three years. Is there any change in doing the CT technology, especially assessing the coronary arteries or other vessels which are leading from the heart to the brain?
</b> Yeah, there are a lot of changes taken place so far the.
</b> I am here on cardiac pulmonary embolism and he underwent an echo test. There was no evidence of pulmonary embolism by echo. We found there is very trivial TR. The RA and the RV were absolutely normal. Pulmonary artery pressure was absolutely normal and there was no evidence of thrombus anywhere, but as he went for CT, he wanted to know whether it is a coronary event and while doing his CT, they got it that is a filling defect in the RPA and LPA. You find a pulmonary embolism is the disease, which can be diagnosed very meticulously and in a more effective manner as compared to echo, so far his RPA, LPA or NPA is concerned and even the peripheral vessel of the pulmonary artery.
</b> CT is excellent modality so far PE is concerned. In fact, while I was working at Apollo I had had given a thesis work to my DNB students, d-dimer versus CT angio. We found lot of patients where d-dimer was negative still we could get the pulmonary in chest pain and it was with the present CT scans are even tertiary vessel, smaller embolism you can detect.
</b> The decision where you want to ask this patient to one of our doctors who had a pulmonary embolism in the RPA and LPA and we put this patient on heparin. He was in All Indian Institute of Medical Sciences and after giving heparin, there was a little debate to reassess whether there is dissolution of the thrombus or not. We did an echo and we found echo was almost normal. There was nothing much in the echo to say. But the debate was, should he go for CT angio or should he go for ventilation/perfusion scan, and ultimately the patient decided himself, he is a doctor, he is a cardiologist. He said “no, I will prefer to go for ventilation/ perfusion scan.” When the ventilation/perfusion scan was done in the Nuclear Center, it was absolutely clear. So he presumed that there is no need for going for a CT because he was scared of the radiation. What is your review on this?
</b> No, with the modern dual energy CT scanner, we can do ventilation/perfusion study as well as CT angio simultaneously with the ideal value what is there, but regression of the thrombus, even it is partial recanalized or 70% there is still thrombus outside. Perfusion will be normal. How to know? What is resolution of the thrombus?
</b> My question is a number of times we have to decide how long to give anticoagulants because in this particular patient he had some surgical intervention for varicose veins since sclerotherapy so this was a likely source. He had no primary cause and there was no secondary cause here except what I mentioned to you is the sclerosing of the varicose veins. So even if you find there is a residual thrombus, will it make a difference, so far, the therapeutic intervention is concerned or we take it for granted that any such patient whose ventilation/perfusion scan is normal,we give for six month anticoagulants and there is no need of CT angio.
</b> It is a normal protocol, once d-dimer should be there, once thrombus is there, once you assess them fast now would you go for chronicity, if it is not resolved it will calcify, it will make a partial luminal that will go for chronic stage, so then there will be in late stage there may be double chronic pulmonary, thrombolic hypertensions. These are various aspects.
</b> What is the protocol? Should we or should we not subject this patient for CT angio?
</b> That is on the clinical assessment absolutely.
</b> What is the protocol? The reason is as I mentioned to you echo was clear. The patient is asymptomatic now, when he came to the hospital, the only slightest exertion while he is speaking.
</b> Truly speaking, on this regards, I have not got any protocol to the best to my knowledge might be there, but I do not know I am confessing.
</b> It is very-very important I think Dr. M. L. Bera has mentioned very clearly that CT angio has got a huge scope, we should not be worried. We can use the contrast which is very-very specific and will not produce addition of insult to the compromised kidney state. We can use the contrast in the small dose. It will not deteriorate the renal functions and he also mentions very clearly that CT angio has a huge role on the contrary role better than the echo for deduction of thrombus burden especially in the right pulmonary artery or left pulmonary artery or even the peripheral vessel of the pulmonary artery and he says though there is no appropriate protocol, but the patient can be followed meticulously may be after three months or six months to see how much is the residual clot.
</b> I am really thankful to both Dr. Mona Bhatia and Dr. M. L. Bera for giving me very, very important information on the imaging technology in the years to come.